Nutritional support in acute pancreatitis: from physiopathology to practice. An evidence-based approach.

Acute Pancreatitis (AP) is a potentially fatal syndrome, associated with a hyper-catabolic state as well as early and late complications that may lead to multi-organ failure and death. Clinical researches produced in recent years suggest that acute pancreatitis may benefit from early oral or enteral nutrition. Nevertheless, many clinicians still believe erroneously that fasting - particularly in the early phase - may reduce AP complications and mortality. The goal of our review is to demonstrate that such false belief may harm the patients and that the whole management paradigm must change, adopting a more rational, evidence-based approach. First, we will describe AP physiopathology and the clinical assessment of its severity. Then we will discuss evidence-based data supporting early oral or enteral nutrition in AP. Finally, we will offer some practice recommendations as regards nutritional support.

Preventing hospital malnutrition: a survey on nutritional policies in an Italian University Hospital.

BACKGROUND: A proper strategy for fighting hospital malnutrition should include nutritional screening of all hospitalized patients, adequate utilization of the Hospital facilities - such as Clinical Nutrition Services or Nutrition Teams - and an adequate algorithm for the adoption of proper nutrition support (oral, enteral or parenteral) with proper timing. The main aim of the present study was to investigate the current policies of different non-intensive wards of our institution (a 1100 beds University Hospital) in terms of prevention of hospital malnutrition. METHODS: We conducted a one-day survey to verify the current policies of nutritional screening and the indication to nutritional support in adult patients, interviewing nurses and physicians of our non-intensive hospital wards. RESULTS: A total of 29 wards were considered, which sum up to 755 hospitalized patients. We found that nutritional screening at admission is routinely assessed only in 41% of wards and that oral nutrient intake is controlled regularly only in 72%. Indication to clinical nutrition support and specifically to artificial nutrition is not consistent with the current international guidelines. Only 14% of patients were receiving artificial nutrition at the moment of the survey and the majority of them were given parenteral nutrition rather than enteral feeding. CONCLUSION: Our survey confirmed that in large hospitals the main barriers to the fight against hospital malnutrition are the lack of knowledge and/or commitment by nurses and physicians as well as the lack of well-defined hospital policies on early nutritional screening, surveillance of nutritional status and indication to nutrition support.

Treating nonthyroidal illness syndrome in the critically ill patient: still a matter of controversy.

The nonthyroidal illness syndrome (NTIS) is a clinical condition of abnormal thyroid function tests observed in patients with acute or chronic systemic illnesses. The laboratory parameters of NTIS usually include low serum levels of triiodothyronine, with normal or low levels of thyroxine and normal or low levels of thyroid-stimulating hormone. It is still a matter of controversy whether the NTIS represents a protective adaptation of the organism to a stressful event or a maladaptive response to illness that needs correction. Multiple studies have investigated the effect of thyroid hormone replacement therapy in certain clinical situations, such as caloric restriction, cardiac disease, acute renal failure, brain-dead potential donors, and burn patients. Treating patients with NTIS seems not to be harmful, but there is no persuasive evidence that it is beneficial. The administration of hypothalamic releasing factors in patients with NTIS appears to be safe and effective in improving metabolism and restoring the anterior pituitary pulsatile secretion in the chronic phase of critical illness. However, also this promising strategy needs to be explored further. Anyhow, an extremely prudent approach is needed if treatment is given. Much of the data appearing in the literature on the treatment of NTIS encourage further randomized controlled trials on large number of patients. At present, however, we believe that there is no indication for treating thyroid hormone abnormalities in critically ill patients until convincing proof of efficacy and safety is provided.

Unusual presentation of leptospirosis in the late stage of pregnancy.

Here we report a case of leptospirosis without fever during the late stage of pregnancy in which the initial clinical presentation was more suggestive of a pregnancy-related liver dysfunction rather than an infectious disease. A 32-year-old primipara at 37 week of gestation was hospitalised with a 10-day history of nausea, vomiting, and abdominal pain without fever. Initial routine blood tests showed hyperbilirubinemia, a moderate increase in transaminase levels, severe coagulopathy and an increased creatinine level. On clinical suspicion of pregnancy-related liver dysfunction such as HELLP syndrome (hemolysis, elevated liver enzyme levels, low platelet count) or acute fatty liver of pregnancy (AFLP), emergency caesarean section was performed and a healthy baby was delivered. Postoperatively, the patient was stable, but 5 days later she developed clouding of consciousness, severe jaundice and respiratory failure. At this time, an infectious disease was considered and leptospirosis was confirmed by serological tests. In conjunction with intensive care management, antibiotic therapy was given; the patient was discharged in good condition and her baby did not develop signs of active leptospirosis. While leptospirosis is rare in pregnancy, this is the first report of acute infection without fever mimicking the clinical pattern of HELLP syndrome or AFLP

Comparison of positive end-expiratory pressure with reverse Trendelenburg position in morbidly obese patients undergoing bariatric surgery: effects on hemodynamics and pulmonary gas exchange.

BACKGROUND: Anesthetized morbidly obese patients often exhibit impaired pulmonary gas exchanges, mostly because of a reduction in functional residual capacity. At present, several approaches are suggested to ventilate these patients. METHODS: The efficiency of positive end-expiratory pressure (PEEP) and reverse Trendelenburg position (RTP) were compared in order to improve oxygenation in 20 morbidly obese patients undergoing bariatric surgery. RESULTS: Both PEEP and RTP determined a significant decrease in alveolar-arterial oxygen difference and an increase in total respiratory compliance (Ctot). RTP resulted in lower airway pressures than PEEP with similar improvements in Ctot and oxygenation. Concerning hemodynamic parameters, cardiac output (CO) significantly decreased with both PEEP and RTP. CONCLUSIONS: RTP and PEEP can be considered adequate ventilatory settings for morbidly obese patients, without any significant difference with regard to gas exchange improvement. However, the decrease in CO may partially counteract the beneficial effects on oxygenation of these ventilatory settings.

Volatile anesthesia in bariatric surgery.

BACKGROUND: Obesity causes anesthesiologists a broad variety of perioperative theoretical and practical problems. The aim of this study was to compare two protocols of anesthesia employing Isoflurane and Sevoflurane and evaluate the cardiorespiratory parameters, postoperative recovery and analgesia. METHODS: 90 patients underwent biliopancreatic diversion. 60 patients (group A) received Isoflurane and 30 patients (group B) were anesthetized with Sevoflurane. Intraoperative monitoring consisted of EKG, invasive arterial pressure, SpO2, EtCO2, Etanest, Spirometry, urinary output and TOF. Cardiorespiratory parameters and end tidal expiratory concentrations of volatile agents were collected during specific phases of surgery: 1) before induction of anesthesia, 2) after intubation, 3) after skin incision, 4) after positioning of costal retractors, 5) in the reverse Trendelenburg position, 6) end of surgery. During the postoperative period the Aldrete test was carried out to evaluate the recovery from anesthesia. VAS was administered for 6 hours after the end of surgery to set the quality of analgesia. RESULTS: No statistically significant differences in cardiorespiratory parameters were found between the two groups. Extubation time was significantly less in the Sevoflurane Group than in the Isoflurane (15 +/- 7 min vs 24 +/- 5 min, p < 0.05). The Sevoflurane Group showed an Aldrete score significantly higher than the Isoflurane (8.8 +/- 0.3 vs 8.1 +/- 0.4, p < 0.05). VAS values did not show statistical differences. CONCLUSION: The introduction of Sevoflurane, a volatile agent with rapid pharmacokinetic properties, seems to offer an interesting application in these patients.

Bispectral index monitoring in sevoflurane and remifentanil anesthesia. Analysis of drugs management and immediate recovery.

BACKGROUND: Recent studies have suggested that electroencephalogram bispectral index (BIS) monitoring can improve recovery after anaesthesia and save money by shortening patients postoperative stay. The aim of the study is to evaluate the management of drugs and to measure immediate recovery after anaesthesia with or without BIS monitoring. METHODS: We studied 90 patients undergoing abdominal surgery randomly allocated to one of two groups of 45 each with or without BIS monitoring. Standard monitoring (EKG, arterial oxygen saturation and non-invasive blood pressure) was applied. All groups were monitored with BIS, using electrodes (Zipprep, Aspect Medical Systems) applied to the forehead. In the group 2 the BIS value was blinded to the anaesthesiologist. The BIS value was displayed using Spacelabs Medical BIS Ultraview Monitor. After obtaining baseline values for the BIS index (group 1) and haemodynamic data (all groups) anaesthesia was induced with a bolus dose of remifentanil and TPS, and vecuronium. The anaesthesia was maintained with Remifentanil and Sevoflurane. At standard times BIS, haemodynamic and respiratory parameters were recorded. Recovery times were measured by a study coordinator. Drug consumption was calculated. RESULTS: In group 1 the consumption of Sevoflurane decreased by 40 % while the consumption of remifentanil decreased by 10 % as compared to group 2. The use of vecuronium did not change in the 2 groups. In group 1 the time elapsed from cessation of anaesthetics to orientation decreased significantly. The difference was 5 min, from 11 to 6 min. CONCLUSIONS: BIS monitoring decrease both sevoflurane and remifentanil consumption, when compared to anaesthesia without BIS, with an immediate recovery after sevoflurane and remifentanil anaesthesia.

Pain therapy in elderly cancer patients.

In most (65-80%) cancer patients at an advanced stage of illness we find significant, invalidating symptoms of pain. Cancer pain is a complex pain (with a nociceptive, neuropathic and deafferentation component), which requires a multidisciplinary approach (surgery, radiochemotherapy, and pain therapy). Pain therapy has various pharmacological strategies at its disposal (opiates, anti-inflammatory and adjuvant drugs) together with modulation and neurodestructive techniques, which must be applied taking account of both the stage of the disease and the pain intensity. In elderly patients, a careful, tailored management of pharmacological therapy is required. In older age, personality disorders are also to be found (anxiety, depression, hypocondria and feeling of abandonment), which make therapy more complex and varied. Knowledge of these problems will, however, make it possible to control cancer pain in elderly patients to the best possible effect and improve the quality of life in the advanced and terminal stages.